Kay Moore Scholarship Application 2025

Kay Moore Scholarship

Name

First Last

Gender Identity

Date of Birth

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Cell Phone

Primary Diagnosis

Date of Diagnosis

Are you on treatment?

Yes

If NO, what's your off treatment date?

Provide a Brief Description of Your Treatment and Current Health

Physician's Name

Treatment Center

Phone

School – GPA/SAT/ACT

Please fill out this section and attach a transcript* signed by a school official.

Grade Point Average (unweighted, based on a 4.0 scale)

Transcript Attached:

Yes

If no, the transcript can be sent by the school directly, emailed to scholarships@specialove.org. School info/transcripts must be for the most recent semester completed. For graduating seniors a high school or undergraduate transcript is acceptable.

Special Love Involvement

Please indicate what Special Love programs you participated in, and years participated.

Camp Fantastic

Years Attended:

Fantastic Friends

Years Attended:

OctoberFest Weekend

Years Attended:

Ski Family Weekend

Years Attended:

Fantastic Winter Weekend

Years Attended:

YAC Weekend

Years Attended:

Tidewater Weekend

Years Attended:

Reunion Weekend

Years Attended:

Summer Family Day

Years Attended:

Other:

Years Attended:

Section B: College/University/Trade School Information

Name and address of school to whom you have formally committed and are planning to attend. OR If you have not yet chosen a school, list any to which you have applied. Be aware a scholarship award will not be provided until you have provided evidence of enrollment.

School Name(s) & Address

Student ID # (if different from SSN)

Degree and/or Area of Study:

Is this a graduate level program?

Yes

When is tuition due at the institution? Indicate Fall & Spring Semester's due dates.

Tuition cost per semester:

If not living at home, what is your housing cost per semester:

Average number of credits you plan to take per semester:

Total Credit Hours:

Are you financially independent and responsible for your own cost of living?

If you answered yes, you yourself should complete the financial information.

Do you live with your parent(s)/guardian(s) when not at school?

If you answered yes, your parents/guardians should complete the financial information.

Financial Support

Your application will NOT be reviewed if the information in Section B is incomplete. Applicants who live independently and will cover their own educational expenses should fill out this section themselves in its entirety.

Annual Income:

List sources of income:

Average Monthly Rent Expense:

Average Monthly Utility Expense:

Average Monthly Car Payment Expense:

Average Monthly Insurance Expense:

Average Monthly Food Expense:

Average Monthly Incidentals Expense:

List all scholarships and/or financial aid applied for, noting if they have been approved, or not.

For applicants who live at home, parents/guardians should fill out this section in its entirety.

Annual Gross Household Income:

Do you own your own home?

If YES, what is the value of your home's equity?

(Market value, minus the mortgage balance)

List all outstanding debts over $1,000:

Press the + sign on the right of the field to add more lines.

Will applicant contribute to his/her post-secondary expenses?

If YES, in what way?

Describe any specific information currently influencing your family’s financial need in meeting the applicant’s post-secondary educational costs (i.e. medical bills, loss of job, family illness, etc.):

Section C – Written Essay

Provide a one-page essay on how this scholarship award would help to finance your post-secondary education. NOTE: Applications without a written statement will not be considered. Essay must include; 1) Why you feel you should be considered for this scholarship 2) Role Special Love played in your treatment and recovery, and; 3) Any residual effects from your cancer. 4) Your planned educational goals You may also attach additional letters of reference at your discretion.

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